M21-1MR, Part IX, Subpart i, Chapter 4

Chapter 4. Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)

1. General Eligibility for CHAMPVA
Introduction
/ This topic contains information on general eligibility for Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), including
  • a general description of CHAMPVA
  • the eligibility requirements for survivors and dependents
  • requirements for CHAMPVA
  • entitlement to CHAMPVA after termination of remarriage
  • provisions of Public Law (PL) 107-330, and
  • handling qualifying disabilities certified during the Veteran’s lifetime.

Change Date
/ November 16, 2004
a. General Description of CHAMPVA
/ The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) provides reimbursement for most medical expenses, such as
  • inpatient
  • outpatient
  • mental health
  • prescription medication
  • skilled nursing care, and
  • durable medical equipment.

b. Eligibility Requirements for Survivors and Dependents
/ Eligibility requirements for medical care for survivors and dependents of certain Veterans are covered by CHAMPVA per 38 U.S.C. 1718.

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1. General Eligibility for CHAMPVA, Continued

c. Requirements for CHAMPVA
/ To be eligible for CHAMPVA, an individual must be
  • the spouse or child of a Veteran whom the Department of Veterans Affairs (VA) has rated as 100 percent permanently and totally disabled for a service-connected (SC) disability
  • the surviving spouse or child of a Veteran who
died from a VA-rated SC disability, or
at the time of death was rated 100 percent permanently and totally disabled, or
  • the surviving spouse or child of a military member who died in the line of duty, not due to misconduct.

d. Entitlement to CHAMPVA After Termination of Remarriage
/ Ancillary benefits such as CHAMPVA will not be awarded to recipients of Dependency and Indemnity Compensation (DIC) pursuant to 38 U.S.C. 1311(e), for a surviving spouse who regained eligibility for DIC either upon the termination of remarriage by death, divorce, or annulment, or upon the cessation of living with another person and holding himself or herself out openly to the public as that person’s spouse (VAOPGCPREC 13-98), for the period from 10-1-98 through 11-30-99.
The Veterans’ Millennium Health Care and Benefits Act, Public Law (PL) 106-117, reinstated the surviving spouse’s entitlement to ancillary benefits effective December 1, 1999. Entitlement to these benefits was not made retroactively.
e. Provisions of PL 107-330
/ PL 107-330, The Veterans Benefits Act of 2002, effective February 4, 2003, provides for the retention of CHAMPVA eligibility for surviving spouses who remarry after age 55. For those individuals who remarried after age 55 but prior to the effective date of this law, eligibility may be established only if an application is received between February 5, 2002, and February 4, 2003.
f. Handling Qualifying Disabilities Certified During the Veteran’s Lifetime
/ If a qualifying disability was certified to Veterans Health Administration (VHA) during the Veteran’s lifetime, CHAMPVA does not routinely make further requests concerning
  • the status of disability as of date of death, or
  • whether or not death was SC.

2. Specific Entitlement to CHAMPVA
Introduction
/ This topic contains information on specific entitlement to CHAMPVA, including information on
  • requests for information on CHAMPVA eligibility
  • the procedure for checking the Health Administration Center (HAC) web site for CHAMPVA eligibility
  • notifying claimants about potential CHAMPVA entitlement
  • completing the CHAMPVA eligibility request
  • notifying the applicant of CHAMPVA entitlement or nonentitlement
  • notifying HAC of subsequent changes in dependency status affecting eligibility to CHAMPVA, and
  • notifying HAC when VA discontinues a Veteran’s permanent and total disability rating.

Change Date
/ August 15, 2011
a. Requests for Information on CHAMPVA Eligibility
/ Previously, the VHA Health Administration Center (HAC) forwarded requests for eligibility information on VA Form 10-3884a, Exchange of Beneficiary Information and Request for Eligibility Data - CHAMPVA by mail or fax to the regional offices (ROs).
Designated employees in the Veterans Service Center (VSC) must now identify open cases by checking the HAC web site at
b. Procedure for Checking HAC Web Site for CHAMPVA Eligibility
/ Follow the steps in the table below to check the HAC web site for CHAMPVA eligibility information.
Step / Action
1 / Print the cases from the HAC dated Excel spreadsheet that apply to the station.
2 / Complete the printable WordVA Form 10-3884a for each case.
Note: An online version of VA Form 10-3884a may be downloaded from

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2. Specific Entitlement to CHAMPVA, Continued

b. Procedure for Checking HAC Web Site for CHAMPVA Eligibility(continued)
Step / Action
3 / Check the Veterans Information Solution (VIS) web interface to determine whether eligibility information is available. If available, notify HAC.
Important: Ratings prior to 2000 will be unavailable through the VIS application.
Reference: For more information on VIS, see the VIS User Guide.
4 / Return the VA Form 10-3884a either by e-mail, fax, or mail to the HAC Eligibility Section at the following address:
HealthAdministrationCenter (741/PASS)
Eligibility Unit
PO Box 469028
Denver, CO 80246-9028
Fax: 303-370-7710
Note: These alternative fax numbers may also be used to return VA Form10-3884a to the HAC: 303-331-7809 or 303-331-7820.
Notes:
  • First time users must register using their first name, last name, station number, and e-mail address. The employee will then receive a password by e-mail.
  • Users should regularly access the web site and check the Excel spreadsheet as HAC will update the site daily except for holidays.

c. Notifying Claimants About Potential CHAMPVA Entitlement
/ Information about potential entitlement to CHAMPVA benefits, and instructions on how to apply for them, are contained in the VA Form 21-8765,Service-Connected Death Award Attachment. It is sent to the payee, surviving spouse, or child with the processing of an initial award of SC death benefits.

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2. Specific Entitlement to CHAMPVA, Continued

d. Completing the CHAMPVA Eligibility Request
/ Follow the steps in the table below to complete the CHAMPVA eligibility request verifying the
  • relationship of the applicant to the Veteran, and
  • existence of a qualifying SC disability or death.

Step / Action
1 / Use the criteria contained in 38 CFR 3.50 through 38 CFR 3.58 to establish the relationship of the claimants to the Veteran. Identify established dependents by
  • name
  • date of birth of children
  • relationship, and
  • helpless child or school child status (including the period for which school attendance is approved).

2 / State whether
  • the Veteran currently has a permanent and total disability
  • at the time of death, the Veteran had a permanent and total SC disability, as described in M21-1MR, Part IX, Subpart ii, 2.1
  • the Veteran’s death after separation from service was SC, as described in M21-1MR, Part III, Subpart ii, 7.5.d
  • the Veteran died in service, as described in M21-1MR, Part IV, Subpart iii.1.2.

3 / If the claimed SC disability or relationship is not established, annotate the eligibility request to that effect.

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2. Specific Entitlement to CHAMPVA, Continued

d. Completing the CHAMPVA Eligibility Request(continued)
Step / Action
4 / After completing the eligibility request
  • file a copy of the response in the claims folder (and in the Dependents’ Educational Assistance (DEA) folder for any schoolchild receiving Chapter 35, Educational Assistance)
  • return the original eligibility request to the CHAMPVACenter for their control in accordance with VHA RCS 10-1,Section XXII, Item No 136-4
  • on the left flap, back-file the folder copy so it remains on top of all subsequent folder material, and
  • annotate the copy for the DEA folder, “NotifyCHAMPVACenter of any extension of dependency status or unscheduled termination of dependency” as described in M21-1MR, Part IX, Subpart i, 4.2.f.

e. Notifying the Applicant of Decision Regarding CHAMPVA Entitlement
/ Notification of the decision regarding entitlement is provided directly to the claimant by the medical activity, not the VSC.
However, if a notice of disagreement (NOD) or substantive appeal is received as the result of denial of basic eligibility to medical treatment, authorization activity is responsible for furnishing the statement of the case (SOC) and certification of appeal to the claimant.
f. Notifying HAC of Subsequent Changes in Dependency Status Affecting Eligibility
/ If dependency status is extended by school attendance beyond the date previously verified, or if dependency terminates earlier than the date furnished on the eligibility request, promptly advise the HAC Eligibility Section of the
  • date and nature of the change, and
  • name and file of the Veteran and the dependents affected.

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2. Specific Entitlement to CHAMPVA, Continued

g. Notifying HAC When VA Discontinues a Veteran’s Permanent and Total Disability Rating
/ When VA discontinues a Veteran’s permanent and total disability rating, promptly notify the HAC Eligibility Section by faxing a copy of the revised rating decision to (303) 370-7710.
Note: These alternative fax numbers may also be used to submit the revised rating decision to the HAC: (303) 331-7809 or (303) 331-7820.

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